Dyer & Beck: Psychocardiology.

Electronic J ournal of Applied Psychology. Psychocardiology. 3(2): 3-12(2007)

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Psychocardiology: Advancing the Assessment and Treatment of Heart Patients

Jade Dyer (jade.dyer@med.monash.edu)
School of Psychology, Psychiatry and Psychological Medicine
Monash University, Caulfield VIC 3145 Australia

Dr Neil Beck (drneilbeck@drneilbeck.com)
The Family NeuroHealth Centre
88 Broadway, Nedlands WA 6009 Australia


Abstract
Heart disease is the leading cause of death worldwide
and can be effectively improved using a variety of
behavioural and psychosocial interventions. Despite
wide support for the inclusion of psychological
interventions in cardiac rehabilitation programs, it has
been indicated that these services are often poorly
promoted and underutilized. Furthermore, while
programs may frequently employ psychological
techniques, they are most often not implemented by
psychologists. This article aims to review the most recent
research into key psychological issues in cardiology and
their relevance to treatment in clinical practice. The
application of theory and best practice guidelines for
cardiac care in the Australian healthcare system is
discussed.

Keywords: Psychocardiology; Health Psychology;
Cardiac; Rehabilitation; Healthcare; Psychosocial
Introduction
Heart disease is currently the leading cause of death
worldwide, in both high and low income countries
(Lopez et al., 2006). Although men and women from all
backgrounds are affected, it is well established that
psychosocial and behavioural risk factors influence
which individuals will develop the disease (Day, 2001).
Emotional states, cognitive patterns, personality
variables, poor dietary choices, lack of exercise and
smoking have been shown not only to contribute to the
development of cardiovascular pathology, but also to
the recurrence of cardiac events (Keil, 2000; Smith &
Ruiz, 2002). Despite the widely acknowledged efficacy
of psychological interventions in bringing about
improved emotional states, cognitive restructuring and
behavioural change, these strategies are rarely applied
in the treatment of cardiac patients (Jordan, Barde, &
Zeiher, 2007). Furthermore, psychosocial, educational
and behavioural interventions are often delivered by
healthcare workers of various specialties rather than
those with the most expertise in this area, such as
clinical or health psychologists. Thus, expansion of the
field of psychocardiology and the application of clinical
health psychology to the care of patients with heart
disease by appropriate professionals may offer an
opportunity to significantly advance the health and
well-being of cardiac patients.
This article aims to review the most recent research
into key psychological issues in cardiology and their
relevance to treatment in clinical practice. The utility of
current psychological assessment and intervention tools
will be critically examined in relation to major
biopsychosocial risk factors for heart disease and the
application of these psychological methods in the
Australian healthcare system will be discussed.
Affectivity and Psychosocial Prognostic Factors
Anxiety, Depression and Hostility Epidemiological and
experimental evidence has long suggested that anxiety
and depression predict morbidity and death from
coronary heart disease (CHD), even after controlling for
biological risk factors such as serum cholesterol and
blood pressure. (Kubzansky & Kawach, 2000). In a
recent German study, 76 patients with myocardial
infarction (MI) completed the Lubeck Interview for
Psychosocial Screening (LIPS) to assess their anxiety
levels and were monitored for cardiac events during the
following 31 months. Patients with high anxiety scores
suffered more cardiac events in total and these occurred
earlier than in non-anxious patients, although anxious
patients were more likely to continue smoking and to
report use of alternative medicine, which may have
confounded the results (Benninghoven et al., 2006).
Women, diabetics and patients without partners were
also more likely to suffer further cardiac events, which
demonstrates that even in this small sample, identifying
the individual contributions of biological and
psychosocial risk factors to health outcomes presents a
significant methodological challenge due to the multi-
factorial etiology of MI.
Interestingly, depression did not predict subsequent
cardiac events in this study and similar inconsistent
results have plagued much of the research into the
effects of negative emotional states on CHD. This has
been particularly notable in relation to anger and
hostility, which have been associated with CHD for
decades with only mixed research support (Krantz &
McCeney, 2002). Given the overlapping characteristics
of anger, anxiety and depression, Suls and Bunde
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(2005) have suggested that the disposition toward
negative affectivity be viewed as a unitary construct in
future research. Although the neurogenic mechanisms
underlying the increased risk of CHD due to emotional
reactions remain unclear (Critchley et al., 2005), there
is little debate that negative emotional states are
frequently detrimental to the rehabilitation of cardiac
patients and can be measured using psychological
instruments such as the LIPS. In clinical practice, the
danger may be in testing for only one emotional state
when types of negative affectivity co-occur and may
require combined treatment.

Personality and Social Support To address the
effects of multiple negative emotional states on the
development and prognosis of cardiac disease, a new
personality construct has been proposed. This
personality profile, referred to as Type D or
distressed, is characterized by high scores on
measures of negative affectivity and social inhibition
and was associated with a fourfold increase in cardiac
death among men with CHD in a preliminary
investigation (Sher, 2004). Although this construct
requires further research support, it may have the
potential to identify those most at risk of serious cardiac
complications and allow for more effective targeting of
interventions for these psychological risk factors.
An examination of anxiety levels in 417 patient-
spouse pairs using the Multiple Affect Adjective
Checklist indicated that spouses were more anxious
than cardiac patients and higher levels of spousal
anxiety were associated with worse patient scores on
the Psychosocial Adjustment to Illness Scale (Moser &
Dracup, 2004). Increased partner anxiety and perceived
overprotection by partners were also associated with
lower health-related quality of life in 82 cardiac patients
in a recent study (Joekes, Van Elderen, & Schreurs,
2007), suggesting that partners of heart patients may be
in need of psychological intervention to improve their
own wellbeing and that of their partners.
Assessing Behavioural Risk

Diet and Physical Activity Physical inactivity,
obesity and diets high in saturated fat are known to
contribute to the development of CHD and the
frequency of acute cardiac events (Mann, 2002).
Dietary adjustments and additional exercise are
therefore required to reduce the risk of cardiac disease
and it has been suggested that self-efficacy, or ones
belief in their ability to perform or succeed, may predict
success in making these lifestyle changes. Linde and
colleagues (2006) examined this theory by asking 349
participants in a weight loss trial to complete a modified
version of the Weight Efficacy Life-Style Questionnaire
and to report levels of activity, dietary details and
weight before, during and after the trial. Results showed
higher self-efficacy scores were associated with greater
engagement in behaviors that promote weight loss, such
as following eating or exercise plans, counting calories
and decreasing dietary fat intake. Although the sample
did not contain cardiac patients, self-efficacy may also
predict eating and exercise behaviours in clinical
populations and could assist in the planning of
treatment programs for those with high or low
expectations of their abilities.
Another cognitive theory, the Theory of Planned
Behaviour (TPB), has been used as a framework for
understanding the motivation to exercise during cardiac
rehabilitation. According to TPB, intention to perform
certain actions determines if these behaviours will be
achieved. Further to this, intention is determined by
positive or negative attitudes towards the behaviour,
perceived social pressure to perform the behaviour and
the perceived control or difficulty in performing the
behaviour. Using TPB as a framework, Blanchard,
Courneya, Rodgers, Daub and Knapik (2002) examined
the attitudes, subjective norms, perceived control and
intentions to exercise of 81 patients enrolled in a
cardiac rehabilitation program. Attitudes and intentions
were measured using ratings on seven-point Likert
scales and assessed in relation to observed and reported
exercise. Regression analysis indicated attitudes,
subjective norms and perceived control explained 51%
of the variance in intention to exercise and intention
explained 23% of the variance in exercise adherence.
TPB may therefore be useful in understanding the
motivation to exercise and designing interventions to
address cognitive influences that increase physical
activity.

Intervention Attendance Before a patient can
adhere to behavioural treatments prescribed during
cardiac rehabilitation, they must first attend. To identify
psychological variables that may influence attendance,
Whitmarsh, Koutantji and Sidell (2003) asked 93
cardiac patients to complete the Illness Perceptions
Questionnaire, the Hospital Anxiety and Depression
Scale and the Coping Orientation to Problems
Experienced questionnaire and examined the results in
relation to rehabilitation attendance. The non-
attendance of 32 patients was best predicted by negative
beliefs regarding the controllability or curability of their
illness and use of maladaptive coping strategies, such as
denial, mental or behavioural disengagement and
venting of emotions. In contrast, attenders were more
likely to use problem or emotion focused coping
strategies, had greater distress, perceived the symptoms
and consequences of their illness to be more severe and
had less strong beliefs that their illness was caused by
external factors such as germs. Results suggest that
certain beliefs and coping strategies contribute to non-
attendance at cardiac rehabilitation, thus raising the
possibility that immediate education and coping skills
training after diagnosis could improve attendance and
generate subsequent benefits in patient health outcomes.

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Psychological Interventions in Cardiac
Rehabilitation

The Multisite Cardiac Lifestyle Intervention
Program In 1983, Dean Ornish and colleagues
published an influential study in which 46 heart patients
participated in an intensive 3.5 week lifestyle
modification program in a rural setting or were assigned
to a control group receiving standard medical care. The
residential program involved participants observing a
strict, low-fat, vegetarian diet, learning healthier food
buying and preparation habits, and practicing
meditation and relaxation 5 hours per day. After
participating in this intervention, patients showed a
44% increase in the duration of exercise, a 20%
decrease in cholesterol and a 91% decrease in angina
episodes compared to the control group (Ornish et al.,
1983). A later study using the same intervention found
a 15% reduction in the narrowing of the arteries in the
experimental group, while the mean diameter stenosis
worsened in the control group by 15% during the same
period (Ornish et al., 1990).
Since 1983, methods of cardiac rehabilitation have
continued to involve dietary changes, education and
stress reduction techniques. In 2007, Ornish was
involved in an evaluation of the Multisite Cardiac
Lifestyle Intervention Program, which indicated that the
reduced dietary fat intake and increased hours per week
of exercise and stress management produced by the
program lead to reductions in coronary risk factors,
including weight, cholesterol, hostility and stress
(Daubenmier et al., 2007). Analyses of variance showed
fat intake, hours of exercise and stress management
contributed separately to patient outcomes but produced
a greater effect together, suggesting an interactive
relationship between variables. Despite the success of
the interventions described in reducing risk factors for
cardiac disease, critics of the Ornish approach have
claimed such radical lifestyle change is unlikely to
appeal to most patients and is difficult to achieve in
clinical practice (Linden, 2000). However, recurring
myocardial infarctions and sudden cardiac death are
less likely to appeal to patients and deteriorating health
due to untreated cardiac disease may lead to life-
changing restrictions and anxieties that prove more
drastic than an extremely healthy lifestyle.

Cardiac Rehabilitation and Implanted
Cardioverter Defibrillators Implanted Cardioverter
Defibrillators (ICDs) are automated devices implanted
under the skin that continuously monitor

the heart
rhythm and deliver electrical shocks to correct
potentially fatal ventricular

arrhythmia (Goldberger &
Lampert, 2006). ICDs markedly improve survival in
patients at risk of sudden cardiac death but research has
indicated that patients who receive an increased number
of life-saving shocks have higher anxiety, reduced well-
being and poorer physical functioning than patients who
receive no shocks or those without ICDs (Irvine et al.,
2002; Schron et al., 2002; Thomas et al., 2006). English
researchers thus evaluated the efficacy of a cognitive-
behavioural rehabilitation program in assisting patients
to adjust to ICD implantation. The program
incorporated exercise, consultation with a
physiotherapist, progressive muscle relaxation,
breathing retraining, meetings with electrocardiogram
technicians and maximal exercise tests to demonstrate
the level of exertion that could be reached without
producing a shock. Educational sessions focusing on
cognitive models of anxiety and negative thinking,
discussion regarding the function of the ICD and
ongoing support from a cardiac nurse were also
included. Participants were assessed using The Hospital
Anxiety and Depression Scale, The ICD patient Total
Concerns Questionnaire, The MacNew Quality of Life
after Myocardial Infarction Questionnaire, EuroQual
and The Shuttle Test, yielding significantly improved
scores on all measures post treatment compared with
baseline (Frizelle et al., 2004).
The improvements in anxiety, depression, emotional,
physical, social and global quality of life, perceived
health status and maximal exercise indicated by the
improved test scores suggest cognitive-behavioural
therapy is effective in patients with ICDs. However, the
sample was small and 74% of those invited to
participate declined, suggesting that the experimental
group may have been particularly motivated to improve
their adaptation to the heart patient lifestyle.
Furthermore, test score improvements were small and
the intervention was extensive, generating questions as
to the cost and feasibility of conducting these
interventions on a larger scale. Interestingly, more than
50% of patients attended with their spouses despite
partners not being invited. Spouses reported the
intervention helped them cope with their own anxiety
about the ICD, suggesting again that partners should be
included in future psychosocial interventions for heart
patients.

The SAFE-LIFE Essen Heart Program Though
many lifestyle intervention programs have had
encouraging results, findings remain mixed. In the
recent SAFE-LIFE Program, 101 patients participated
in a year long group-based intervention involving
educational lectures, CBT and relaxation training.
Mediterranean diet, regular exercise and daily activity
were recommended during the sessions. Cognitive
restructuring, coping skills training and a choice of
relaxation techniques were offered, including
mindfulness meditation, guided imagery, yoga
breathing techniques and body scan. Adherence to the
program was excellent, with only 3 patients attending
less than 90% of the sessions, and quality of life
measures were significantly improved in the
experimental group compared to controls. However,
while physical functioning was also improved, there
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were no significant changes in psychological outcomes,
as measured using the Beck Depression, Spielberger
State/Trait Anxiety, Spielberger State/Trait Anger and
Perceived Stress Inventories (Michalsen et al., 2005).
In contrast to the previous studies that provided
control groups with only medical care, the SAFE-
LIFE program provided the control group with printed
educational materials. It is therefore possible that
psychoeducation is equally as effective in a written
format as in a group-based format. The 1 year
timeframe may also have allowed for greater
psychological adjustment than more brief interventions,
thereby decreasing the difference between groups. In
addition, women showed significant improvements in
depression and trait anger scores when analysed
separately, as a result of having significantly worse
scores than men at baseline. This suggests that research
into cardiac rehabilitation in women is necessary, as
most research to date has had predominantly male
samples. Furthermore, as it has previously been found
that cardiac patients with low levels of stress gain less
benefit from psychological interventions (Frasure-
Smith, 1991), it may be advantageous to determine the
threshold level of psychological distress above which
treatment is most useful.

Smoking Cessation Smoking contributes to the
development of cardiovascular morbidity and increases
the risk of recurrence of MI and sudden death in
patients with heart disease (J unnila & Runkle, 2006).
Given that smoking cessation is strongly associated
with decreased cardiac events and reduces the relative
risk of mortality in CHD patients by 36% (Critchley &
Capewell, 2003), it is surprising that cardiac
rehabilitation programs so rarely include interventions
to target smoking. This notable absence may be partly
due to the ineffectiveness of current brief interventions.
Spencer and Anderson (2004) examined the effects of a
minimal-contact smoking cessation intervention
involving brief counseling by a nurse, self-help
materials, advice and aftercare by a cardiologist and
found no difference between the rates of abstinence in
intervention and control group cardiac inpatients after 1
year. Similarly, an earlier study of a 20-30 minute
intervention conducted while patients were in hospital
after MI showed no differences in smoking cessation of
the intervention and control group after 6 weeks or 1
year (Hajek, Taylor, & Mills, 2002). This intervention
included carbon monoxide readings, booklets, a quiz,
contact with other people giving up, a declaration of
commitment to give up and a sticker in the patient notes
to remind staff to reinforce anti-smoking messages at
follow-up.
While brief interventions delivered by medical staff
have been ineffective at reducing smoking in cardiac
patients, a recent meta-analysis of 19 randomized
controlled trials compared standard medical care with
psychosocial interventions of at least 1 month duration
and concluded that behavioural therapy, telephone
support and self-help material increased quit rates in
CHD patients (Barth, Critchley, & J urgen, 2006).
Although there is substantial heterogeneity in smoking
cessation interventions and their results, an earlier
review also found a 15% increase in quit rates among
cardiac patients participating in interventions.
Furthermore, this positive effect was greater when
programs involved a counselor and 3 to 5 months of
relapse prevention (France, Glasgow, & Marcus, 2001).
Relapse prevention treatment models emphasize the
role of situational variables and coping responses in
abstinence from cigarettes. According to this model,
coping skills aimed at reducing stress and negative
thinking, problem-solving and increasing assertiveness
should increase self-efficacy and reduce the probability
of relapse. This approach was recently compared with a
treatment based on the Health Belief Model, which
involved educational strategies to alter patient
perceptions of susceptibility, consequences and severity
of cardiac disease and the benefits or barriers to quitting
smoking. Although both treatments were suboptimal for
the total intervention group of 160 women with cardiac
risk factors, results indicated women with low self-
efficacy were more likely to quit as a result of relapse
prevention treatment than educational strategies
(Schmitz, Spiga, Rhoades, Fuentes, & Grabowski,
1999). Thus, individually tailored interventions that
incorporate cognitive factors, such as level of self-
efficacy, may improve smoking cessation in cardiac
patients.
Theoretical Overview

A thorough examination of the expansive literature
relating to psychosocial and behavioural factors in
cardiac disease is beyond the scope of this paper.
However, even a brief review of current literature
reveals some prominent themes. Firstly, although there
have been mixed research findings in many areas, there
is little doubt that emotional, cognitive, social and
behavioural variables have a large impact on the
development and trajectory of heart disease.
Inconsistent experimental findings therefore appear to
be a result of methodological difficulties due the
multifaceted aetiology of cardiac events, which not only
involve an array of risk factors but also a complex,
synergistic interaction between variables. One approach
to this problem has been to investigate which
combination of treatments is most effective, by
evaluating holistic rehabilitation programs, rather than
to assess each factor in isolation. While a standard
treatment is preferable under experimental conditions
for reasons of consistency, individualized treatment
may be more effective in clinical practice, given the
differing contribution of various biopsychosocial
factors to each individuals recovery. Thus, increasing
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assessment of patient needs may be an integral part of
future cardiac rehabilitation.
A second theme emerging from the current literature
is the relative neglect of the social needs of the cardiac
patient. Three of the studies reviewed identified
partners as important in determining quality of life post-
diagnosis, yet no interventions were designed to
accommodate those who support the patients in daily
life. Thirdly, although rehabilitation programs typically
incorporated many psychological treatment strategies,
interventions were predominantly conducted by medical
staff. As only 39% of physicians and nurses reported
comfort in managing emotional issues in a recent
national survey (Sears et al., 2000), the integration of
psychologists into cardiac care settings may prove
beneficial to treatment outcomes due to the high
involvement of emotions in the progression of heart
disease. Despite being a major biopsychosocial risk
factor, smoking was often unaddressed by rehabilitation
programs, presumably to avoid confounding
experimental results. As smoking involves erroneous
cognitive biases, conditioned learning and social
pressures in addition to physical addiction, smoking
cessation is another area in which psychologists may be
useful. In sum, although research is inconsistent in this
area, psychosocial and behavioural factors remain
linked to the progression of cardiac disease. However,
clinical health psychology principles have been only
marginally applied by the mental health professionals to
cardiac care in research settings thus far.
Psychocardiology in Practice: Australian
Perspectives

In 1999, Goble and Worcester documented best
practice guidelines for cardiac rehabilitation and
secondary prevention on behalf of the Department of
Human Services in Victoria (Goble & Worchester,
1999). This report identified behavioural modification,
psychosocial interventions, exercise training, education,
counseling, and vocational rehabilitation as the key
components of heart patient rehabilitation and claimed
that Australia had a large network of programs to
provide these services. However, the National Heart
Foundation of Australia published a recommended
framework for cardiac rehabilitation in 2004, which
concluded that existing services were underutilized due
to lack of initial referral and poor patient attendance
(Heart Foundation, 2004). Both the Heart Foundation
and the World Health Organisation (WHO, 1993)
recommend that cardiac rehabilitation services should
be available and routinely offered to everyone with
cardiovascular disease, and can be considered adequate
when most cardiac patients can return to their normal
activities, lead enjoyable, productive lives and have
reduced risk of further cardiac events. Thus, there
appears to be some disparity between the intervention
that is ideally recommended and that which is
delivered. Differences and similarities between
research-based best practices and the cardiac care
currently provided in the community and will therefore
be discussed, with reference to selected Australian
services.
Southern Health Heart Failure Program

A Chronic Disease Management Model of Care
Clinical psychologist Dr Donita Baird enabled a brief
tour of the Southern Health Hospital Admission Risk
Program (HARP) at Monash Medical Centre in April
2007 and offered an inside perspective on the success of
their Chronic Heart Failure (CHF) Program. As with
most of the cardiac rehabilitation interventions reported
to be effective in research settings, the CHF program
involves a multipronged approach. Firstly, nurses
deliver education regarding the adverse symptoms of
CHF such as fluid retention and instructions on how to
self-medicate when necessary. Physiotherapists develop
and monitor home-based exercise activities and a
pharmacist monitors patient adherence to medication
regimens and answers patient questions regarding their
medicines. After an initial assessment within a month of
discharge, patients attend follow-up visits to a
cardiologist at 3 and 12 months and receive ongoing
support by phone or home visit, which encourages self-
management and compliance with therapy. Finally,
patients are screened for depression and anxiety, and
referred to the psychologist as needed.
To be eligible for the Southern Health Heart Failure
Program, patients must have had an echocardiogram
indicating decreased ventricular function, been recently
admitted to hospital with symptoms associated with
CHF and be at high risk for exacerbation of these
symptoms. Patients must also have a Medicare Card
and not be seeing a private cardiologist. Attendance at
the CHF clinic is free of charge but the Southern Health
CHF Rehabilitation Exercise Program can incur a fee.
While the presence of strict criteria does not fulfill the
aim propounded by WHO to offer services to every
person with cardiovascular disease, the use of objective
assessment processes and protocols ensures that
patients are receiving the most appropriate care.
Patients who are not likely to benefit from the CHF
program can therefore be referred to a more suitable
service. As 80% of men and 70% of women with heart
failure under the age of 65 live less than eight years
post-diagnosis (Marzilli, Affinito, & Focardi, 2006) and
50% of all CHF patients are likely to be dead within 3
years (DHS, 2003), this group was targeted by Southern
Health due to their high need for continued
multidisciplinary intervention.
In accordance with the chronic disease management
model of care developed by Southern Health, the CHF
program aims not only to improve patient outcomes, but
also to reduce avoidable hospital admissions and
Emergency Department presentations. As with all
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streams of the HARP Program, which include projects
targeting respiratory conditions, diabetes and other
complex or chronic conditions, the CHF program has
the additional aims of empowering patients through
education and self-management strategies and ensuring
equitable access to health care for all (DHS, 2006). In
the interests of achieving these objectives, HARP
systems are holistic, client focused and integrated with
community based care.

Evaluation of the HARP CHF Program At the
2005 Australian Cardiovascular Health and
Rehabilitation Association conference in Fremantle,
Western Australia, Dr Baird presented a comparison of
the Southern Health CHF intervention with similar
programs in the United States, the United Kingdom and
Sweden. Although only in its initial stages, patients
participating in the Southern Health program were
walking greater distances in the 6MW functional
capacity test, had increased quality of life scores on the
Minnesota Living with Life questionnaire, and showed
lower scores on the Cardiac Depression Scale (Baird &
Everard, 2005). These promising trends did not reach
statistical significance at that time, due to small sample
sizes, but the program continues to undergo regular
evaluations and is now achieving statistically
significant indicators of efficacy. The length of hospital
stays for CHF patients has been reduced from 8 to 6
days (DHS, 2003) and HARP patients in general have
35% less emergency presentations, 52% less hospital
admissions and 41% fewer days in hospital according to
a recent public report (DHS, 2006).
Patients in the Southern Health CHF Program are
invited to involve their partner or carer in all stages of
the intervention, in contrast with treatment conducted in
research settings, which has often neglected to include
significant others. The Heart Foundation takes this a
step further by recommending that the whole family be
involved in treatment (Heart Foundation, 2004).
Although all patients receive services from a similar
range of at least 5 health professionals, the physical,
medical, educational and psychological interventions
delivered are tailored to the needs of the patient. This
adaptable, client-centred mode of care therefore differs
from the standardized treatments often used in research
investigations. Another key feature of HARP, which
has been the focus of little research, is the relationship
between cardiac patients and their general practitioners.
Poor inter-provider and patient-provider
communication has, however, been identified as a
major cause of preventable hospital readmissions and
poor patient outcomes in the wider population (Naylor,
2003). Furthermore, it has been demonstrated that the
relationship between providers and CHF patients can be
strengthened by support staff through provider
education, learning about physician management plans
and accompanying the patients to their first
appointments (McCauly, Bixby, & Naylor, 2006). As
there is also evidence that adherence to medical
regimens for other chronic diseases such as diabetes
(Maddigan, Majumdar, & Johnson, 2005) and HIV
(J ohnson et al., 2006) is affected by patient-provider
communication, it is likely that the collaboration and
partnership between hospitals, primary care and the
community is vital to the success of the HARP CHF
program.
One characteristic shared by many research protocols
and the CHF program is the lack of support for smoking
cessation. Dr Baird reported that smokers are referred to
Quit Victoria, as they provide the most specialised
services in that area. Quit is a joint initiative of The
Cancer Council Victoria, VicHealth, the Department of
Human Services and the Heart Foundation, and
provides online Quit-Coaching, a telephone helpline,
Quit Courses and extensive educational resources for
those attempting to give up smoking. As longer term
interventions with telephone support and self-help
material have been found to promote smoking cessation
and short-term interventions delivered by medical staff
have not, Quit Victoria appears to provide evidence-
based practice that is congruent with the ethos of the
HARP Program. However, while Quit has branches in
all states, they do not all offer the same range of
services and are often predominantly health promotion
agencies rather than providers of client support.
Furthermore, it was noted by Dr Baird that although
patients are often referred to community agencies such
as Quit they will often not engage with these
organisations, particularly if there is a minimal cost
involved.
The Heart Foundation

A Nationwide Community Service The Heart
Foundation is an independent, non-profit health
organisation, created with the aims of improving the
heart health of Australians and reducing disability and
death from heart disease. Although it is in many ways a
health promotion agency, promoting research into the
prevention of heart disease and advocating heart healthy
behaviour in the community at large, the Heart
Foundation is also one of the main providers of support
to cardiac patients. Working with hospitals and
community health centres, the Foundation has
established cardiac rehabilitation programs throughout
Australia and has helped many thousands of people
with heart disease to enjoy an active life through
programs of support, education and information.
Educational support for cardiac patients is available
via email or telephone through Heartline, the Heart
Foundations nationwide information service. The
helpline provides advice on heart conditions, blood
pressure, healthy eating, quitting smoking, physical
activity, surgery and treatment, rehabilitation, and
weight management, and handles around 80,000
inquiries per year. Advisory staff are available from
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9
8:30 am to 6:30pm on weekdays for the cost of a local
call. The Heart Foundation also provides opportunities
for behavioural modification of physical activity levels
through programs such as Heartmoves. Specifically
designed for people living with heart conditions,
Heartmoves exercise classes are conducted in
community venues all over Australia and incorporate
weights, stretching, T'ai Chi, Yoga, aerobics and aqua-
aerobics.
A recent evaluation of Heartmoves by NSW Health
Demonstration Research Project indicated that although
40% of patients in cardiac rehabilitation were interested
in the program, 29% were advised by health
professionals to participate and only 7% attended.
However, over 90% of participants were satisfied or
completed satisfied with all aspects of the program
(NSW Department of Health, 2004). These results
suggest that improved patient-provider communication
and referral are again vital to advancing the holistic care
of heart patients. As indicators of self-efficacy and
intention have been shown to predict exercise
adherence, use of these psychological measures may
also increase attendance to programs such as
Heartmoves. It is interesting to note that although
meditation and other relaxation strategies have been key
elements of successful cardiac rehabilitation in
experimental studies, these psychological interventions
are rarely emphasized by community groups such as the
Heart Foundation.

HeartNET In response to the dearth of psychosocial
support for cardiac patients in Western Australia, the
WA Division of the Heart Foundation and Edith Cowan
University recently began funding the development of
an online therapeutic community called HeartNET. This
web-based intervention provides members with a forum
for patient-to-patient communication, using discussion
boards and private messaging, and allows heart patients
and carers to offer mutual therapeutic support. As most
cardiac rehabilitation services are based in urban areas,
both Heartline and HeartNET are designed to cater for
people in regional and remote areas, as well as those in
major cities. The site currently has over 600 members
and has resulted in heart patients initiating a buddy
system to support each other in their physical activity
and exercise efforts (Bonniface, Omari, & Swanson,
2006). In addition to empowering each other to
maintain healthy lifestyles, members have also had the
opportunity to provide the emotional support that is
often absent in cardiac rehabilitation programs. For
example, dialogue analysis has revealed that
participating in HeartNET can relieve the depression
and despair of the newly diagnosed in relation to their
new functional limitations and the frustration at family
and friends for misunderstanding the implications of
their condition (Bonniface, Green, & Swanson, 2005).
As negative affectivity has long been associated with
poorer health outcomes in cardiac patients, relief of
these feelings may be an important element drawing
people to the HeartNET site.
Members of HeartNET were recently invited to share
their experiences and views of cardiac rehabilitation on
the discussion board. Although all responders had been
referred to rehabilitation and attended, some had been
through various other treatments before this occurred
and expressed frustration that they had been informed
about the available services earlier. Comments on the
value of the interventions were overwhelmingly
positive and usually focused on the physical activity
components, but some participated in 4 week stress
management classes and meditation. Education was
also mentioned as a beneficial aspect, as was the
opportunity to meet other people with similar
conditions and experiences. It is interesting to note that
although most of the 146 services listed in the directory
of cardiovascular health programs for New South Wales
and the Australian Capital Territory do offer
psychosocial interventions such as stress management,
counseling and family support, many of these were
optional streams or available by request (Heart
Foundation, 2006). This may result in improved
targeting of interventions towards those most in need,
but may also lead to an underutilization of services if
patients are not aware of the psychosocial support that
is available or the benefits this could offer them
personally.
Clinical Health Psychology in Cardiac Care

In their examination of chronic heart failure models
of care in the United States, United Kingdom and
Sweden, Baird and Everard (2005) noted that although
all services identified the need for psychological
interventions, none had a psychologist on staff. Dr
Baird commented that this was the case in many places
around Australia as well. Given that the application of
psychological assessments and interventions in the
treatment of heart disease has had considerable success
in the past, why are psychologists not more widely
employed in this area? There is the possibility that
psychologists attract reasonably high fees and that
psychological interventions can be implemented for less
cost by other health professionals. However, the
challenge of applying traditional psychological
knowledge to the new area of physical health may be
the major concern for both the medical system and the
counseling psychologists themselves (Belar et al.,
2001). While it is recommended that all psychologists
undergo continual professional development throughout
their career and are able to attain competency in many
fields, the development of clinical health psychology as
a specialization may confer significant benefits to the
healthcare system in the area of chronic or lifestyle
diseases.
Health psychologists are particularly well-equipped
to work in the field of psychocardiology for several
Dyer & Beck: Psychocardiology.
Electronic J ournal of Applied Psychology. Psychocardiology. 3(2): 3-12(2007)
10
reasons. Firstly, they are required to have knowledge of
healthcare delivery systems and the roles of other health
professionals. Thus, working in the medical system
requires no special adjustment, as this is part of their
initial training and ongoing experience. In contrast to
many psychological specializations, health psychology
is primarily based on biopsychosocial frameworks,
which focus on how interactions between physical
systems of the body, psychological predispositions and
social networks influence health and illness. As the
development of heart disease involves all these
elements, understanding the interactive relationship
between them is essential to effective education and
intervention. Furthermore, topics on which health
psychologists have extensive specialized knowledge are
also directly relevant to the treatment of cardiac
patients. These include the effects of stress, anxiety and
depression on illness, self-management of chronic
conditions, eating problems, addictions, and coping
with terminal illness, bereavement, disability and
rehabilitation (APS, 2007). Finally, the assessment of
psychological factors in chronically ill populations and
designing interventions to improve coping and quality
of life are core functions of clinical health psychology.
As heart patients often have multiple co-morbidities
such as diabetes and chronic pain, these skills may be
applied to a variety of conditions by health
psychologists in the care cardiac patients.
Conclusions
There is currently a wide range of cardiac
rehabilitation services available in Australia that
incorporate psychosocial support and are clearly based
on research evidence and best practice guidelines. The
Southern Health Heart Failure Program is one example
of such a program and has demonstrated efficacy in
addressing the needs of each patient, improving patient
outcomes and decreasing hospital admissions. Despite
this, heart patients remain under-serviced due to the
failure of health practitioners to refer eligible patients
and the reluctance of patients to participate for
individual reasons. As research suggests non-attendance
is influenced by erroneous health beliefs and
maladaptive coping strategies, psychological
intervention may help to remedy this situation.
Facilitation of positive patient-practitioner
communication and greater promotion of the programs
to primary care physicians, hospital staff and the
community are also likely to improve referral and
attendance.
While it is encouraging to see a range psychological
principles being applied to the treatment of heart
patients, psychologists are still rarely included in the
multidisciplinary healthcare teams employed in this
field. Considering that clinical health psychologists
receive training specifically in the application of
behaviour modification techniques, health education
and psychosocial intervention in chronically ill
populations, the addition of psychologists with this
specialization to cardiac rehabilitation teams may
significantly improve patient attendance and outcomes.
Health psychologists also receive training in health
promotion and may use these skills to increase
awareness of rehabilitation programs, as this appears to
be a key area of underdevelopment in current cardiac
care. Although vocational rehabilitation was
recommended in earlier DHS best practice guidelines
for cardiac rehabilitation, this service was not included
in any of the programs examined and may also present
a possible avenue for further expansion of
interventions. As clinical health psychology principles
have been only marginally applied by the appropriately
trained professionals to cardiac rehabilitation, there are
strong possibilities for advancement in the treatment of
heart patients in the near future.
Acknowledgments
This project was made possible by the knowledgeable
support of Dr Donita Baird, Dr Nicole Rinehart and Dr
Leesa Bonniface.
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Correspondence to: J ade Dyer
The Family NeuroHealth Centre
Suite 9, 88 Broadway, Nedlands WA 6009
jade.dyer@med.monash.edu
Research Profile
J ade Dyer is a graduate student of Health Psychology
at Monash University. Her previous research has
explored the neuropsychology of executive function
and the psychophysiology of migraine. Her major
interests include pain, psychoneuroimmunology,
biofeedback and the psychological effects of disease or
illness. She is currently undertaking a research project
supported by the Heart Foundation and Edith Cowan
University.
Dr Neil Beck is a medical doctor and has been in
private practice in Western Australia for over 40 years.
He specializes in the treatment of addictions and
substance abuse, sexual dysfunctions and the
underlying psychological conditions that contribute to
these problems. His major interests include mood and
attention deficit disorders. He is also the best selling
author of Beating Heroin.